Low FODMAPs Diet

by Sue Kira, Naturopath & Clinical Nutritionist

Overview of the Low FODMAPs diet

Stage 1 – The Elimination phase

Foods to avoid and foods to eat during the Elimination phase

Stage 2 – The Reintroduction (challenge) phase

Conclusion

Case study: IBS cleared with Low FODMAPs diet

Overview of the low FODMAPs diet

FODMAP stands for: Fermentable Oligo-saccharides, Disaccharides, Monosaccharaides and Polyols (see if you can remember that for a trivia quiz). These fermentable sugars include lactose, glucose, fructose, fructans, galacto-oligosaccharides, maltitol, mannitol, isomalt and xylitol.

FODMAPs are found naturally in all sorts of common everyday foods such as fruits, vegetables, legumes and grains, or in other words, carbohydrate foods.

All plant based foods (and some other substances) contain FODMAPs, and the amount of FODMAPs within individual foods can be low, medium or high. FODMAP foods are beneficial for our digestive system because they have a prebiotic affect, meaning they feed our beneficial bacteria.

However, high FODMAPs foods are commonly poorly digested by many people and instead get fermented by gut bacteria (both good types and bad types), producing a host of gastrointestinal symptoms. The most common FODMAPs culprits are the onion family, garlic, legumes and brassica family of vegetables, so if you get ‘windy’ after eating these foods then there’s a pretty good chance you have this issue, at least to some degree.

The challenge is to determine the level of FODMAPs your body can tolerate so you continue to receive the benefits of these foods, without getting the strong reactions.

Often FODMAP sensitivity can be due to having SIBO (small intestine bacterial overgrowth) and once this has been resolved you will often be able to tolerate these foods much better. Some people will be fine with most of these foods provided they only have small amounts and steer away from onions and legumes, for example.

The FODMAPs diet was developed by a team of doctors at Monash University in Melbourne, Australia and evolved to assist those with IBS (irritable bowel syndrome) and FGID (functional gastrointestinal disorder).

This diet comprises of two stages

The first is the elimination phase where you eliminate all medium and high FODMAPs foods and only eat low FODMAPs foods for a period of 3-8 weeks. The time frame will depend on how quickly your symptoms settle. The second stage is the re-introduction phase where you re-introduce each of the food groups back into your diet, while observing any foods that set off your symptoms again.

Some people find there are only one or two foods that upset them, while for others, there can be many foods. A lucky few will be able to eat all the foods after having a break from them, provided they only eat small amounts of these foods.

For those people who find that removing the high and medium FODMAPs foods doesn’t help, or they react to many of the foods re-introduced back into their diet, then further exploration needs to be done. Some may have SIBO (Small Intestine Bacteria Overgrowth) that needs to be treated with herbs and/or antibiotics plus the SIBO Diet; others may need to look at other intolerances, such as high histamines etc.

This is for you to explore with your health practitioner. Don’t give up, keep looking until you find out what causes your symptoms. Diagnosis can be made with breath tests at specialised clinics, or kits which can often be purchased on-line or from a practitioner, or you can find out by following this diet.

Common symptoms of FODMAPs sensitivity

• Abdominal pain and discomfort
• Bloating
• Wind/gas (usually smelly)
• Distension (abdominal swelling)
• Altered bowel habit (ranging from diarrhoea to constipation)

What conditions can benefit from a low FODMAP diet?

Its primary use is to relieve digestion-related symptoms, but it is also emerging as a useful tool to support conditions such as:

• Irritable Bowel Syndrome (IBS)
• Inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn’s disease
• Other forms of Functional Gastrointestinal Disorder (FGID)
• Small intestinal bacterial overgrowth (SIBO)
• Certain auto-immune conditions like rheumatoid arthritis or multiple sclerosis
• Skin conditions like eczema or psoriasis
• Fibromyalgia
• Migraines that appear to be triggered after certain meals

Where are FODMAPs found?

Fructose: a monosaccharide fruit sugar found in most fruits and vegetables

Lactose: a disaccharide sugar found in dairy foods like milk

Fructans: an oligosaccharide similar to fructose is found in many vegetables and grains

Galactans: an oligosaccharide found primarily in legumes.

Polyols: sugar alcohols like xylitol, sorbitol, maltitol and mannitol. You find them mainly in artificial sweeteners, chewing gum, sugar free lollies and mints.

Other FODMAP ingredients such as inulin (from chicory root), natural flavours, high fructose corn syrup, agave, honey, etc are often added into foods, so check labels for hidden sources of FODMAPs.

Is gluten a FODMAPs?

FODMAPs exist in carbohydrates such as dairy products, all leguminous foods and many fruits and vegetables. Gluten is a protein and not a carbohydrate. However, while gluten is technically not a FODMAP, foods that contain gluten often have high FODMAP content, whereas gluten-free products are typically lower in FODMAPs, which can be a good alternative and beneficial for those with FODMAP sensitivities.

Stage 1 – The Elimination phase

Following a low FODMAPs diet may seem restrictive to some people because it cuts out numerous common foods and food groups. But others see it differently because the Low FODMAPs diet only runs for a short period of time and there can be so many benefits for their health. Also, there are many yummy foods to select that they may have never tried and enjoyed before.

The idea of the Elimination phase is to restrict all medium and high FODMAPs from your diet for 3-8 weeks (depending on how quickly your symptoms resolve) to give your gut bacteria a chance to correct any imbalances and your digestive system time to heal. A period shorter than three weeks can occasionally be used if you have had hydrogen breath testing to identify which specific FODMAPs are the most problematic. Otherwise it’s likely you will require at least three weeks for the body to adjust and ‘reset’.

After this time, you begin the Reintroduction phase, where it is important to reintroduce the medium and high FODMAP foods you eliminated to see what triggers symptoms.

Following is a list of foods to avoid and foods you can eat during the first phase. You will notice the foods are separated into groups; the significance of these will be explained in the reintroduction phase.

Foods to avoid and foods to eat during the Elimination phase

The following lists show foods to avoid during the Elimination Stage, and acceptable foods to eat during this time. The lists do not cover all foods.

Don’t despair if you think you are going to ‘miss out’ on certain foods, it’s not for long. Instead, focus on all the great foods you can eat from the following acceptable lists.

Fruits to avoid

 Group 1: Excess Fructose fruit

• Apple
• Mango
• Nashi fruit
• Pear
• Persimmon
• Rambutan
• Watermelon

Group 2: Excess Polyol fruit

• Apple
• Apricot
• Avocado
• Blackberries
• Cherries
• Longan
• Lychee
• Nashi Fruit
• Nectarine
• Peach
• Pear
• Plum
• Prune
• Watermelon

Acceptable fruits

• Banana
• Blueberries
• Boysenberry
• Cantaloupe
• Star fruit
• Cranberry
• Durian
• Grapefruit
• Kiwi
• Lemon
• Lime
• Mandarin
• Orange
• Passion fruit
• Paw paw/papaya
• Pineapple
• Raspberry
• Rhubarb
• Strawberry
• Tangelo

Note: it is best to limit your intake of ‘suitable fruits’ to one serve per meal. e.g. One banana or orange or a handful of blueberries.

Vegetables to avoid

Group 3: Excess Fructose vegetables

• Sugar snap peas

Group 4: Excess Fructan vegetables

• Artichokes (Globe & Jerusalem)
• Asparagus
• Beetroot
• Brussels sprouts
• Cabbage
• Chicory
• Dandelion leaves
• Fennel
• Garlic
• Leek
• Legumes
• Okra
• Onion (brown, white, & Spanish)
• Peas
• Radicchio lettuce
• Shallot
• Spring onion (white section)

Group 5: Excess polyol vegetables

• Avocado
• Cauliflower
• Mushrooms
• Snow peas

Acceptable vegetables

• Alfalfa
• Bamboo shoots
• Bean shoots
• Beans (green)
• Bok choy
• Broccoli (small amounts only)
• Capsicum
• Carrot
• Celery
• Chives
• Choy sum
• Cucumber
• Endive
• Eggplant (this may be troublesome for some)
• Ginger
• Lettuce (may be ok or not)
• Marrow
• Olives
• Parsnip
• Parsley
• Potato
• Pumpkin/winter squash
• Silverbeet/chard
• Spring onion (green section)
• Spinach
• Swede/rutabaga
• Sweet potato
• Taro
• Tomato
• Turnip
• Yam
• Zucchini (this may be troublesome for some; assess individual tolerance)

Note: Onion & the onion family, such as leeks, shallots, garlic are one of the greatest contributors to IBS. Strict avoidance is recommended. There can often be onion hidden in many processed foods and condiments such as chicken salt, vegetable salt, vegetable powder, dehydrated vegetables, stocks, gravies, soups, marinades, & sauces.

Alternatives are:

• Chives and the green part of spring onion (even these can be irritating for some)
• Fresh and dried ginger, coriander, basil, lemongrass, chilli, mint, parsley, marjoram, oregano, thyme, rosemary & other culinary herbs

Group 6: Other FODMAPs foods to avoid

Avoid

• Lactose products including all dairy
• Galactans include all legumes such as baked beans, lentils, kidney beans, soy beans and chick peas. Legumes and pulses may be ok if soaked and sprouted for 12-72hrs before cooking as this makes them easier to digest and breaks down some of the FODMAPs
• Honey
• Corn syrups
• Corn syrup solids
• Chicory (coffee substitute)
• Dandelion tea (as above)
• Inulin (often found in probiotics)
• Artificial sweeteners (often contain polyols)
• Sugar free or low carb sweets, mints, gums, & dairy desserts

Acceptable Alternatives

• Maple syrup (moderation)
• Nuts & seeds (moderation as they do contain some carb that can irritate)
• Rice bran (moderation)

Wheat and other gluten products to avoid (gluten grains contain higher FODMAPs)

• Bread (white, wholemeal, multigrain, sourdough, pita, & rye)
• Pasta & noodles (regular, two-minute, spelt, egg noodles, hokkien & udon)
• Breakfast cereals (containing wheat/gluten, excess dried fruit &/or fruit juice)
• Savoury biscuits (wheat/gluten based)
• Cakes, biscuits & baked goods (wheat/gluten based)
• Pastry & breadcrumbs (made from wheat flour)
• Others (semolina, couscous, bulger wheat)

Suitable alternatives to gluten products

• Rice
• Corn (may bother some people)
• Potato
• Amaranth
• Tapioca
• Quinoa
• Millet
• Buckwheat
• Arrowroot
• Sago
• Gluten free bread
• Gluten free pasta
• Rice noodles
• Gluten free buckwheat noodles
• Gluten free muesli & gluten free cereals
• Corn thins, rice cakes & crackers, gluten free crackers (corn can upset some)
• Buckwheat, polenta, millet, sago, tapioca, rice, & corn flours (as above)

Important

• Avoid alcohol
• Drink plenty of water
• Fresh fruit and vegetables are the best
• All meats, poultry and fish/seafood have no FODMAPs and are fine to eat
• Chew your food well to help digestion
• Limit processed foods (often contain hidden FODMAPs & irritants)
• Limit or avoid processed meats (often contain hidden FODMAPs & irritants)
• Eat in moderation (portion size is fundamental). For example, a small quantity of almonds is considered low FODMAP, but if you eat an entire bowl of almonds then you will eat a high amount of FODMAPs. As with anything we eat, the dose can make the poison.

Probiotics for gut health with FODMAPs

It is hypothesised that the fermentation of FODMAPs upsets the bacterial balance in our gut. Growing evidence shows that many IBS patients have highly irregular gut bacteria. The question is, will the addition of ‘good’ bacteria from probiotics help to manage FODMAP sensitivities better than just the diet alone?

I found with my clients in clinic, that it was beneficial to just do the diet first until the symptoms settled and then introduce some of the good bacteria, otherwise you can get mixed messages if the probiotics give rise to symptoms as they often do. Be aware that many probiotic products actually contain FODMAPs such as inulin and fructo-oligosaccharides, because they are part of the food used to keep the bacteria alive.

Even a small quantity of probiotics can still upset some people’s tummies until things settle with the diet. If you do get symptoms of bloating etc from probiotics, you may need to wait a little longer before introducing them, or consider SIBO as a potential trigger for your symptoms.

Whole food sources of probiotics include fermented foods like kefir, yoghurt and pickled vegetables such as sauerkraut, which are best avoided initially because fermented foods are rich in a food chemical called histamine, which some people are sensitive to. You can always challenge (reintroduce) these later.

Low FODMAPs dining out

At the beginning of a low FODMAPs diet it is much easier if you prepare your own meals at home and then, as you get more familiar with the ‘safe’ foods to eat, you will know what you can order when dining out. Here are some examples:

• Gluten-free bread (not garlic bread)
• Cereals or mueslis that are Paleo style and low fruit work well for breakfast
• Coffee or tea black or with a splash of coconut milk
• Low FODMAPs salad with chicken, meat, fish or nuts and seeds with a dressing of extra virgin olive oil and fresh squeezed lemon juice
• Low FODMAPs vegetables cooked without additives or sauces
• Meat, fish, egg or tofu dishes without sauces or gravies
• Chicken with dairy free egg mayonnaise or plain roasted or pan fried
• Beef steak with mustard rather than sauce
• Carrot, celery and cucumber sticks as a snack
• Popcorn (BYO additive free) at the cinema
• Sushi and sashimi with dairy free wasabi or mayonnaise but not soy sauce

Stage 2 – The Reintroduction (challenge) phase

The second phase of the diet is very important. This is where foods that were restricted in the first phase are reintroduced gradually (challenged) to learn what your individual tolerance level is to different FODMAPs, and also to bring back some of your favourite foods.

Your health practitioner will provide guidance about the reintroduction process to help minimise symptoms and to ensure maximum variety is achieved in your diet. The goal is to have a sustainable diet that is lower in the now known FODMAPs than were originally consumed, but certainly not as restricted as the first phase of this diet.

To be successful, the reintroduction phase must be approached in a systematic fashion. By the end of the reintroduction phase you should have a better understanding of what foods you can and cannot tolerate, and in what quantities.

This is your personal journey to discover the foods that are right for your body.

How does the reintroduction phase work?

During the reintroduction phase, please keep a food diary and note foods trialled and any reactions, so you can pinpoint what foods may not be suitable for your body.

You may have noticed that the restricted foods were in six different groups. These relate to different food types and levels of FODMAPs.

The scientists who invented the low FODMAPs diet suggest reintroducing these groups one at a time, in order of Group 1 to Group 6. This means that you first reintroduce the foods of your choice from Group 1, the excess fructose fruits, see if you get any reactions, and if not, then move onto Group 2, the excess polyol fruits, and so on.

However, if you get a reaction, it does not mean that all foods in that group are an issue for you. For example, when trialling the excess fructan vegetables in Group 4, you may cook a stir fry with various vegies from this group. You get a reaction, yet you are not sure which food or foods upset your system.

You then need to test the foods you like from that group individually. For example, you may find that you can tolerate asparagus, but when you eat onions, you react with bloating and gas. Different foods contain different levels of fermentable sugars.

The idea is to test the group, then if you have a reaction, test the foods you like to eat from that group one at a time. That way you pinpoint the foods that don’t suit you, or may be ok if eaten in small quantities or a different way. For example, garlic and onion are common reactive FODMAP foods, but may be acceptable in a different form such as cooking with a garlic or onion infused olive oil, where you get the taste, with minimal reactions. Another example is to use a small amount of broccoli in a stir-fry rather than a more concentrated form such as a broccoli soup.

When you trial an individual food, you need three days before you move onto the next one to be certain that you don’t get a delayed reaction e.g. you may try chickpeas and be fine for 24 hours and then try asparagus and get wind, but the wind was from the chickpeas that took 48 hours to digest and not the asparagus.

Another approach is to simply trial your favourite foods first from any group, provided you do so one at a time and allow the three-day gap. You might also intuitively know which foods you react to, so you can trial these first and pinpoint the worst culprits. As previously mentioned, the most common reactive FODMAPs foods are the onion family, garlic, legumes and brassica family of vegetables, such as broccoli, Brussels sprouts, cauliflower and cabbage. This method is good if you only have minimal symptoms or have a fair idea of what foods upset your system.

If you keep reacting to all foods trialled then chances are that you have something else going on and your reaction may not be purely from FODMAPs, but may include other things like histamines, salycilates, oxalates, small intestine bacterial overgrowth (SIBO) or simply a food sensitivity or allergy.

Once you know your reactive foods and you have your list, you can try challenging these foods in different ways, such as tiny amounts, as a fermented food, or well-cooked compared to raw. For example, cabbage may cause wind but when fermented as sauerkraut in small amounts it may be well tolerated; or if an onion is cooked for a long period of time such as slow roasting or caramelized, it will often be fine compared to raw or lightly stir-fried onion.

Do not re-challenge any FODMAPs foods until you are symptom-free from the previously tested food, even if it takes more than three days. It will be worth it. If you are unsure about any symptoms check with your health care provider.

Guidelines for the reintroduction phase

• Reintroduction of foods should always be done at home where you are in control of the portions and ingredients.
• Symptoms from a reintroduced food can appear from 30 minutes or up to 3 days later. By recording in a food diary what you ate, the quantities and any symptoms, you can pick up on patterns you may not have otherwise noticed.
• During the entire reintroduction phase, continue to follow the low FODMAP diet, however once a food has been successfully tested you can add it back into your diet.

Conclusion

Important: Before you commence this diet, see your medical or health care professional for qualified guidance. Do not stop any medications or supplements previously prescribed unless advised otherwise by your medical or health care professional, who may even prescribe extra supplementation.

Once the Reintroduction phase is complete and you know which foods you do or don’t react to, you and your practitioner can work out the best ongoing sustainable diet that suits you. Alternatively, simply leave out recipes that include foods you cannot tolerate.

Be aware that there is no such thing as a totally FODMAPs free diet (unless you only ate protein and fats) because all carbohydrates contain some degree of FODMAPs. If you overeat foods considered low in FODMAPs, there still may be too many FODMAPs for your body to handle. It’s important to discern the quantity of individual foods you eat.

During the early stages of your new diet, you may experience symptoms such as fatigue, headaches or body aches, which may occur because your body is detoxifying. However, if you are unsure about a symptom at any time, check immediately with your medical or health care professional.

Case study: IBS cleared naturally with a Low FODMAPs diet

Client name and identifying information changed

Nigel had an embarrassing case of bowel gas that left him feeling reluctant to eat during the day for fear of gassing the office workers with his foul-smelling farts. Not only did he have terrible gas, he frequently had stomach cramps that doubled him over in pain several times a day. Apart from that he seemed quite healthy.

His doctor diagnosed irritable bowel syndrome (IBS). He was told to drink peppermint tea, ginger tea or take muscle relaxant pills. These helped to relieve his symptoms but didn’t treat the cause, which was why Nigel decided to see me.

I suggested tests for SIBO and Leaky Gut, including a hydrogen breath test for fructose malabsorption and a bacterial count of his digestive system, but Nigel couldn’t afford them. So instead we went for the diet options.

Because of Nigel’s English and Indian heritage, he was fond of eating onions and garlic with most of his meals, which alerted me to the possibility that he might be intolerant to FODMAPs, so I suggested a low FODMAPs diet to see if it would help to alleviate his symptoms.

We started with the complete removal of all higher FODMAPs foods as he also ate loads of chickpea hummus, lentils and wheat bread toast, as well as the onions and garlic.

Within three days his symptoms reduced by 75% and by the end of one week he had no symptoms, so we knew we were on track.

I asked him to stay on the low FODMAPs diet for three weeks before reintroducing the foods so his digestive system had time to heal and fully clear the foods.

After three weeks, I suggested he reintroduce the foods that were less likely to be an issue, such as normal fruits and vegetables, but to leave out grains, legumes, pulses and the onion family for the time being. He did this in a bit of a hurry as he intuitively felt that the main foods I suggested to leave till last were going to be the culprits, so instead he introduced all the fruits and vegetables he normally liked to eat in one hit, and did so for a week (not my advice).

But this seemed to work fine for him and he still had no reactions. He kept the fruits and vegetables separated to different meals, because he was aware of good food combining principles to not mix fruits and vegetables at the one meal (which he had tried previously with some success).

When he was ready to trial the legumes, pulses and grains, I suggested to soak them for 24hrs and allow them to sprout before rinsing and cooking them and to only use gluten free grains to help his digestion. This seemed to work quite well, although he still had a small amount of manageable wind, so I suggested that he cut these out again for a few days until we tested the other food ingredients so there was no confusion as to what was causing the wind.

The next group was the onion and garlic family, including leeks, chives and spring onions. These were his favourite foods and he was most disappointed to discover that these foods caused the majority of his pain.

He discovered that if he only had a tiny amount of very well cooked (caramelized) onions once every three days he could get away with that, and he could also tolerate garlic infused oil instead of full garlic cloves in stir fry veggies.

The next challenge was to bring them all together by eating his favourite meal of curried chickpeas with caramelized onion and high FODMAP vegetables cooked in garlic infused oil. This was fine provided he only had one small serve once a week. We found it worked better for Nigel when he diluted the curry with low FODMAPs vegetables, left out onion and garlic and instead used the garlic infused oil plus a few extra spices.

By cooking up a batch of curry, he could eat one serve on the day he made it, then freeze the rest for another day, for about a week later.

That way he could still eat most of the foods he loved and only have minor wind issues, provided he spaced the meals apart.

Nigel also discovered that if he ate curry on a Friday night and even sneaked in a little onion now and then, all would be clear by Monday for work, which was fortunate for him (and for others).

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